A prospective, randomized trial of intravascular-ultrasound guided compared to angiography guided stent implantation in complex coronary lesions: the AVIO trial

Intravascular Imaging-Guided Versus Coronary Angiography-Guided Complex PCI: A Meta-analysis of Randomized Controlled Trials

INTRODUCTION

Trials evaluating the role of intravascular imaging in percutaneous coronary intervention (PCI) for complex coronary artery disease have yielded mixed results. This study aimed to compare the outcomes of intravascular imaging specifically intravascular ultrasound (IVUS) with those from conventional coronary angiography in complex PCI.

METHODS

Comprehensive electronic search of MEDLINE, EMBASE, and Cochrane databases was performed until March 2023 for randomized clinical trials (RCTs) comparing intravascular imaging with coronary angiography in patients undergoing complex PCI. Complex PCI was defined per each study, and included PCI for American College of Cardiology/American Heart Association (ACC/AHA) type B2/C lesions, unprotected left main coronary artery disease, or multivessel stenting. The primary study outcome was major adverse clinical events (MACE).

RESULTS

The meta-analysis included 10 RCTs with a total of 6615 patients (3576 in the intravascular imaging group and 3039 in the coronary angiography group). The weighted mean-follow up was 28.9 months. Compared with coronary angiography, intravascular imaging reduced MACE (8% vs. 13.3%; relative risk [RR] 0.63; 95% confidence interval [CI] 0.54-0.73), cardiac death (RR 0.47; 95% CI 0.31-0.73), definite/probable stent thrombosis (RR 0.48; 95% CI 0.24-0.97), target vessel revascularization (RR 0.62; 95% CI 0.46-0.83), and target lesion revascularization (RR 0.61; 95% CI 0.47-0.79). There was no difference between both groups in all-cause death (RR 0.79; 95% CI 0.53-1.18) and myocardial infarction (RR 0.80; 95% CI 0.61-1.04).

CONCLUSION

In patients undergoing complex PCI, intravascular imaging-specifically IVUS-reduced MACE by decreasing the incidence of cardiac death, stent thrombosis, and target vessel and target lesion revascularization.

Long-term clinical outcomes of intravascular imaging-guided percutaneous coronary intervention versus angiography-guided percutaneous coronary intervention in complex coronary lesions: a systematic review and meta-analysis

Background: In this study, we aim to discuss the long-term clinical outcomes of intravascular ultrasound imaging-guided percutaneous intervention (IVUS-PCI) versus angiography-guided percutaneous coronary intervention (PCI) in complex coronary lesions over a mean period of 2 years. Methods: A systematic search and meta-analysis were conducted to assess the efficacy of using intravascular ultrasound or optical coherence tomography guidance in coronary artery stenting compared to angiography. Results: A total of 11 randomized controlled trials with 6740 patients were included. For the primary outcome, a pooled analysis (3.2 vs 5.6%). For secondary outcomes, the risk was significantly low in image-guided percutaneous intervention compared with angiography. Conclusion: Intravascular imaging-guided PCI is significantly more effective than angiography-guided PCI in reducing the risk of target lesion revascularization, target vessel revascularization, cardiac death, major adverse cardiovascular events and stent thrombosis.

Coronary Angiography, Intravascular Ultrasound, and Optical Coherence Tomography for Guiding of Percutaneous Coronary Intervention: A Systematic Review and Network Meta-Analysis

BACKGROUND

Results from multiple randomized clinical trials comparing outcomes after intravascular ultrasound (IVUS)- and optical coherence tomography (OCT)-guided percutaneous coronary intervention (PCI) with invasive coronary angiography (ICA)-guided PCI as well as a pivotal trial comparing the 2 intravascular imaging (IVI) techniques have provided mixed results.

METHODS

Major electronic databases were searched to identify eligible trials evaluating at least 2 PCI guidance strategies among ICA, IVUS, and OCT. The 2 coprimary outcomes were target lesion revascularization and myocardial infarction. The secondary outcomes included ischemia-driven target lesion revascularization, target vessel myocardial infarction, death, cardiac death, target vessel revascularization, stent thrombosis, and major adverse cardiac events. Frequentist random-effects network meta-analyses were conducted. The results were replicated by Bayesian random-effects models. Pairwise meta-analyses of the direct components, multiple sensitivity analyses, and pairwise meta-analyses IVI versus ICA were supplemented.

RESULTS

The results from 24 randomized trials (15 489 patients: IVUS versus ICA, 46.4%, 7189 patients; OCT versus ICA, 32.1%, 4976 patients; OCT versus IVUS, 21.4%, 3324 patients) were included in the network meta-analyses. IVUS was associated with reduced target lesion revascularization compared with ICA (odds ratio [OR], 0.69 [95% CI, 0.54-0.87]), whereas no significant differences were observed between OCT and ICA (OR, 0.83 [95% CI, 0.63-1.09]) and OCT and IVUS (OR, 1.21 [95% CI, 0.88-1.66]). Myocardial infarction did not significantly differ between guidance strategies (IVUS versus ICA: OR, 0.91 [95% CI, 0.70-1.19]; OCT versus ICA: OR, 0.87 [95% CI, 0.68-1.11]; OCT versus IVUS: OR, 0.96 [95% CI, 0.69-1.33]). These results were consistent with the secondary outcomes of ischemia-driven target lesion revascularization, target vessel myocardial infarction, and target vessel revascularization, and sensitivity analyses generally did not reveal inconsistency. OCT was associated with a significant reduction of stent thrombosis compared with ICA (OR, 0.49 [95% CI, 0.26-0.92]) but only in the frequentist analysis. Similarly, the results in terms of survival between IVUS or OCT and ICA were uncertain across analyses. A total of 25 randomized trials (17 128 patients) were included in the pairwise meta-analyses IVI versus ICA where IVI guidance was associated with reduced target lesion revascularization, cardiac death, and stent thrombosis.

CONCLUSIONS

IVI-guided PCI was associated with a reduction in ischemia-driven target lesion revascularization compared with ICA-guided PCI, with the difference most evident for IVUS. In contrast, no significant differences in myocardial infarction were observed between guidance strategies.

Intravascular imaging-guided coronary drug-eluting stent implantation: an updated network meta-analysis

BACKGROUND

Previous meta-analyses have shown reduced risks of composite adverse events with intravascular imaging-guided percutaneous coronary intervention (PCI) compared with angiography guidance alone. However, these studies have been insufficiently powered to show whether all-cause death or all myocardial infarction are reduced with intravascular imaging guidance, and most previous intravascular imaging studies were done with intravascular ultrasound rather than optical coherence tomography (OCT), a newer imaging modality. We aimed to assess the comparative performance of intravascular imaging-guided PCI and angiography-guided PCI with drug-eluting stents.

METHODS

For this systematic review and updated meta-analysis, we searched the MEDLINE, Embase, and Cochrane databases from inception to Aug 30, 2023, for studies that randomly assigned patients undergoing PCI with drug-eluting stents either to intravascular ultrasound or OCT, or both, or to angiography alone to guide the intervention. The searches were done and study-level data were extracted independently by two investigators. The primary endpoint was target lesion failure, defined as the composite of cardiac death, target vessel-myocardial infarction (TV-MI), or target lesion revascularisation, assessed in patients randomly assigned to intravascular imaging guidance (intravascular ultrasound or OCT) versus angiography guidance. We did a standard frequentist meta-analysis to generate direct data, and a network meta-analysis to generate indirect data and overall treatment effects. Outcomes were expressed as relative risks (RRs) with 95% CIs at the longest reported follow-up duration. This study was registered with the international prospective register of systematic reviews (PROSPERO, number CRD42023455662).

FINDINGS

22 trials were identified in which 15 964 patients were randomised and followed for a weighted mean duration of 24·7 months (longest duration of follow-up in each study ranging from 6 to 60 months). Compared with angiography-guided PCI, intravascular imaging-guided PCI resulted in a decreased risk of target lesion failure (RR 0·71 [95% CI 0·63-0·80]; p<0·0001), driven by reductions in the risks of cardiac death (RR 0·55 [95% CI 0·41-0·75]; p=0·0001), TV-MI (RR 0·82 [95% CI 0·68-0·98]; p=0·030), and target lesion revascularisation (RR 0·72 [95% CI 0·60-0·86]; p=0·0002). Intravascular imaging guidance also reduced the risks of stent thrombosis (RR 0·52 [95% CI 0·34-0·81]; p=0·0036), all myocardial infarction (RR 0·83 [95% CI 0·71-0·99]; p=0·033), and all-cause death (RR 0·75 [95% CI 0·60-0·93]; p=0·0091). Outcomes were similar for OCT-guided and intravascular ultrasound-guided PCI.

INTERPRETATION

Compared with angiography guidance, intravascular imaging guidance of coronary stent implantation with OCT or intravascular ultrasound enhances both the safety and effectiveness of PCI, reducing the risks of death, myocardial infarction, repeat revascularisation, and stent thrombosis.

FUNDING

Abbott.

Cost-Effectiveness of Intravascular Imaging-Guided Complex PCI: Prespecified Analysis of RENOVATE-COMPLEX-PCI Trial

BACKGROUND

Although clinical benefits of intravascular imaging-guided percutaneous coronary intervention (PCI) in patients with complex coronary artery lesions have been observed in previous trials, the cost-effectiveness of this strategy is uncertain.

METHODS

RENOVATE-COMPLEX-PCI (Randomized Controlled Trial of Intravascular Imaging Guidance vs Angiography-Guidance on Clinical Outcomes After Complex Percutaneous Coronary Intervention) was conducted in Korea between May 2018 and May 2021. This prespecified cost-effectiveness substudy was conducted using Markov model that simulated 3 states: (1) post-PCI, (2) spontaneous myocardial infarction, and (3) death. A simulated cohort was derived from the intention-to-treat population, and input parameters were extracted from either the trial data or previous publications. Cost-effectiveness was evaluated using time horizon of 3 years (within trial) and lifetime. The primary outcome was incremental cost-effectiveness ratio (ICER), an indicator of incremental cost on additional quality-adjusted life years (QALYs) gained, in intravascular imaging-guided PCI compared with angiography-guided PCI. The current analysis was performed using the Korean health care sector perspective with reporting the results in US dollar (1200 Korean Won, ₩=1 dollar, $). Willingness to pay threshold was $35 000 per QALY gained.

RESULTS

A total of 1639 patients were included in the trial. During 3-year follow-up, medical costs ($8661 versus $7236; incremental cost, $1426) and QALY (2.34 versus 2.31; incremental QALY, 0.025) were both higher in intravascular imaging-guided PCI than angiography-guided PCI, resulting incremental cost-effectiveness ratio of $57 040 per QALY gained within trial data. Conversely, lifetime simulation showed total cumulative medical cost was reversed between the 2 groups ($40 455 versus $49 519; incremental cost, -$9063) with consistently higher QALY (8.24 versus 7.89; incremental QALY, 0.910) in intravascular imaging-guided PCI than angiography-guided PCI, resulting in a dominant incremental cost-effectiveness ratio. Consistently, 70% of probabilistic iterations showed cost-effectiveness of intravascular imaging-guided PCI in probabilistic sensitivity analysis.

CONCLUSIONS

The current cost-effectiveness analysis suggests that imaging-guided PCI is more cost-effective than angiography-guided PCI by reducing medical cost and increasing quality-of-life in complex coronary artery lesions in long-term follow-up.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03381872.

OPTImized coronary interventions eXplaIn the bEst cliNical outcomEs (OPTI-XIENCE) study. Rationale and study design

INTRODUCTION

Clinical events may occur after percutaneous coronary intervention (PCI), particularly in complex lesions and complex patients. The optimization of PCI result, using pressure guidewire and intracoronary imaging techniques, may reduce the risk of these events. The hypothesis of the present study is that the clinical outcome of patients with indication of PCI and coronary stent implantation that are at high risk of events can be improved with an unrestricted use of intracoronary tools that allow PCI optimization.

METHODS AND ANALYSIS

Observational prospective multicenter international study, with a follow-up of 12 months, including 1064 patients treated with a cobalt‑chromium everolimus-eluting stent. Inclusion criteria include any of the following: Lesion length > 28 mm; Reference vessel diameter < 2.5 mm or > 4.25 mm; Chronic total occlusion; Bifurcation with side branch ≥2.0 mm;Ostial lesion; Left main lesion; In-stent restenosis; >2 lesions stented in the same vessel; Treatment of >2 vessels; Acute myocardial infarction; Renal insufficiency; Left ventricular ejection fraction <30 %; Staged procedure. The control group will be comprised by a similar number of matched patients included in the "extended risk" cohort of the XIENCE V USA study. The primary endpoint will be the 1-year rate of target lesion failure (TLF) (composite of ischemia-driven TLR, myocardial infarction (MI) related to the target vessel, or cardiac death related to the target vessel). Secondary endpoints will include overall mortality, cardiovascular mortality, acute myocardial infarction, TVR, TLR, target vessel failure, and definitive or probable stent thrombosis at 1 year.

IMPLICATIONS

The ongoing OPTI-XIENCE study will contribute to the growing evidence supporting the use of intra-coronary imaging techniques for stent optimization in patients with complex coronary lesions.

Cardiac Optical Coherence Tomography: History, Current Status, and Perspective

For more than 2 decades since the first imaging procedure was performed in a living patient, intravascular optical coherence tomography (OCT), with its unprecedented image resolution, has made significant contributions to cardiovascular medicine in the realms of vascular biology research and percutaneous coronary intervention. OCT has contributed to a better understanding of vascular biology by providing insights into the pathobiology of atherosclerosis, including plaque phenotypes and the underlying mechanisms of acute coronary syndromes such as plaque erosion, neoatherosclerosis, stent thrombosis, and myocardial infarction with nonobstructive coronary arteries. Moreover, OCT has been used as an adjunctive imaging tool to angiography for the guidance of percutaneous coronary intervention procedures to optimize outcomes. However, broader application of OCT has faced challenges, including subjective interpretation of the images and insufficient clinical outcome data. Future developments including artificial intelligence-assisted interpretation, multimodality catheters, and micro-OCT, as well as large prospective outcome studies could broaden the impact of OCT on cardiovascular medicine.

Intravascular Imaging-Guided Percutaneous Coronary Intervention Before and After Standardized Optimization Protocols

BACKGROUND

Although benefits of intravascular imaging (IVI) in percutaneous coronary intervention (PCI) have been observed in previous studies, it is not known whether changes in contemporary practice, especially with application of standardized optimization protocols, have improved clinical outcomes.

OBJECTIVES

The authors sought to investigate whether clinical outcomes of IVI-guided PCI are different before and after the application of standardized optimization protocols in using IVI.

METHODS

2,972 patients from an institutional registry (2008-2015, before application of standardized optimization protocols, the past group) and 1,639 patients from a recently published trial (2018-2021 after application of standardized optimization protocols, the present group) were divided into 2 groups according to use of IVI. The primary outcome was 3-year target vessel failure (TVF), a composite of cardiac death, target vessel myocardial infarction, or target vessel revascularization.

RESULTS

Significant reduction of TVF was observed in the IVI-guided PCI group compared with the angiography-guided PCI group (10.0% vs 6.7%; HR: 0.77; 95% CI: 0.61-0.97; P = 0.027), mainly driven by reduced cardiac death or myocardial infarction in both past and present IVI-guided PCI groups. When comparing past IVI and present IVI groups, TVF was significantly lower in the present IVI group (8.5% vs 5.1%; HR: 0.63; 95% CI: 0.42-0.94; P = 0.025), with the difference being driven by reduced target vessel revascularization in the present IVI group. Consistent results were observed in inverse-probability-weighting adjusted analysis.

CONCLUSIONS

IVI-guided PCI improved clinical outcomes more than angiography-guided PCI. In addition, application of standardized optimization protocols when using IVI further improved clinical outcomes after PCI. (Intravascular Imaging- Versus Angiography-Guided Percutaneous Coronary Intervention For Complex Coronary Artery Disease [RENOVATE-COMPLEX-PCI]; NCT03381872; and the institutional cardiovascular catheterization database of Samsung Medical Center: Long-Term Outcomes and Prognostic Factors in Patient Undergoing CABG or PCI; NCT03870815).

Intravascular Imaging-Guided Versus Angiography-Guided Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis of Randomized Trials

BACKGROUND

Despite the initial evidence supporting the utility of intravascular imaging to guide percutaneous coronary intervention (PCI), adoption remains low. Recent new trial data have become available. An updated study-level meta-analysis comparing intravascular imaging to angiography to guide PCI was performed. This study aimed to evaluate the clinical outcomes of intravascular imaging-guided PCI compared with angiography-guided PCI.

METHODS AND RESULTS

A random-effects meta-analysis was performed on the basis of the intention-to-treat principle. The primary outcomes were major adverse cardiac events, cardiac death, and all-cause death. Mixed-effects meta-regression was performed to investigate the impact of complex PCI on the primary outcomes. A total of 16 trials with 7814 patients were included. The weighted mean follow-up duration was 28.8 months. Intravascular imaging led to a lower risk of major adverse cardiac events (relative risk [RR], 0.67 [95% CI, 0.55-0.82]; P<0.001), cardiac death (RR, 0.49 [95% CI, 0.34-0.71]; P<0.001), stent thrombosis (RR, 0.63 [95% CI, 0.40-0.99]; P=0.046), target-lesion revascularization (RR, 0.67 [95% CI, 0.49-0.91]; P=0.01), and target-vessel revascularization (RR, 0.60 [95% CI, 0.45-0.80]; P<0.001). In complex lesion subsets, the point estimate for imaging-guided PCI compared with angiography-guided PCI for all-cause death was a RR of 0.75 (95% CI, 0.55-1.02; P=0.07).

CONCLUSIONS

In patients undergoing PCI, intravascular imaging is associated with reductions in major adverse cardiac events, cardiac death, stent thrombosis, target-lesion revascularization, and target-vessel revascularization. The magnitude of benefit is large and consistent across all included studies. There may also be benefits in all-cause death, particularly in complex lesion subsets. These results support the use of intravascular imaging as standard of care and updates of clinical guidelines.

Rotational atherectomy combined with cutting balloon to optimise stent expansion in calcified lesions: the ROTA-CUT randomised trial

BACKGROUND

Percutaneous coronary intervention (PCI) of calcified lesions remains challenging for interventionalists.

AIMS

We aimed to investigate whether combining rotational atherectomy (RA) with cutting balloon angioplasty (RA+CBA) results in more optimal stent expansion compared with RA followed by non-compliant balloon angioplasty (RA+NCBA).

METHODS

ROTA-CUT is a prospective, multicentre, randomised trial of 60 patients with coronary artery disease undergoing PCI of moderately or severely calcified lesions with drug-eluting stent implantation. Patients were randomised 1:1 to either RA+CBA or RA+NCBA. The primary endpoint was the minimum stent area on intravascular ultrasound (IVUS). Secondary endpoints included minimum lumen area and stent expansion assessed by IVUS and acute lumen gain, final residual diameter stenosis and minimum lumen diameter assessed by angiography. Clinical endpoints were obtained at 30 days.

RESULTS

The mean age was 71.1±9.4 years, and 22% were women. The procedural details of RA were similar between groups, as were procedure duration and contrast use. Minimum stent area was similar with RA+CBA versus RA+NCBA (6.7±1.7 mm2 vs 6.9±1.8 mm2; p=0.685). Furthermore, there were no significant differences regarding the other IVUS and angiographic endpoints. Procedural complications were rare, and 30-day clinical events included 2 myocardial infarctions and 1 target vessel revascularisation in the RA+CBA group and 1 myocardial infarction in the RA+NCBA group.

CONCLUSIONS

Combining RA with CBA resulted in a similar minimum stent area compared with RA followed by NCBA in patients undergoing PCI of moderately or severely calcified lesions. RA followed by CBA was safe with rare procedural complications and few clinical adverse events at 30 days.

Comparison of Intravascular Imaging, Functional, or Angiographically Guided Coronary Intervention

BACKGROUND

In patients undergoing percutaneous coronary intervention (PCI), it remains unclear whether intravascular imaging guidance or functional guidance is the best strategy to optimize outcomes and if the results are different in patients with vs without acute coronary syndromes (ACS).

OBJECTIVES

The purpose of this study was to evaluate clinical outcomes with imaging-guided PCI or functionally guided PCI when compared with conventional angiography-guided PCI.

METHODS

We searched PUBMED and EMBASE for randomized controlled trials investigating outcomes with intravascular imaging-guided, functionally guided, or angiography-guided PCI. The primary outcome from this network meta-analysis was trial-defined major adverse cardiovascular event (MACE)-a composite of cardiovascular death, myocardial infarction (MI), and target lesion revascularization (TLR). PCI strategies were ranked (best to worst) using P scores.

RESULTS

Our search identified 32 eligible randomized controlled trials and included a total of 22,684 patients. Compared with angiography-guided PCI, intravascular imaging-guided PCI was associated with reduced risk of MACE (relative risk [RR]: 0.72; 95% CI: 0.62-0.82), cardiovascular death (RR: 0.56; 95% CI: 0.42-0.75), MI (RR: 0.81; 95% CI: 0.66-0.99), stent thrombosis (RR: 0.48; 95% CI: 0.31-0.73), and TLR (RR: 0.75; 95% CI: 0.57-0.99). Similarly, when compared with angiography-guided PCI, functionally guided PCI was associated with reduced risk of MACE and MI. Intravascular imaging-guided PCI ranked first for the outcomes of MACE, cardiovascular death, stent thrombosis, and TLR. The results were consistent in the ACS and non-ACS cohorts.

CONCLUSIONS

Angiography-guided PCI had consistently worse outcomes compared with intravascular imaging-guided and functionally guided PCI. Intravascular imaging-guided PCI was the best strategy to reduce the risk of cardiovascular events.

Role of Intravascular Imaging in Complex Percutaneous Coronary Intervention: A Meta-Analysis of Randomized Controlled Trials

Intravascular imaging (IVI) during percutaneous coronary intervention (PCI) has been shown to improve clinical outcomes. However, data is limited in complex PCI and the adoption remains low. We aimed to conduct a meta-analysis of all available randomized controlled trials comparing IVI with conventional angiography in patients who underwent complex PCI. The primary outcomes of interest were major adverse cardiovascular events, all-cause death, cardiovascular death, myocardial infarction, stent thrombosis, target lesion revascularization and target vessel revascularization. Random-effects model was used to calculate pooled risk ratios (RRs) and 95% confidence intervals (CIs). A total of 10 randomized controlled trials comprising 6,368 patients with 3,452 in the IVI group and 2,916 in the angiography group were included. The mean duration of follow up was 2 years, mean age was 65 years and 73% of patients were men. As compared with PCI with routine angiography, the IVI-guided PCI group had significantly lower risks of major adverse cardiovascular events (RR 0.65, 95% CI 0.56 to 0.75, p <0.00001), stent thrombosis (RR 0.57, 95% CI 0.36 to 0.92, p = 0.02), cardiovascular deaths (RR 0.46, 95% CI 0.31 to 0.68, p = 0.0001), target lesion revascularization (RR 0.61, 95% CI 0.48 to 0.78, p <0.0001) and target vessel revascularization (RR 0.62, 95% CI 0.48 to 0.80, p = 0.0003). All-cause deaths and MI were similar in the 2 groups. In conclusion, among patients who underwent complex PCI, IVI reduces adverse events, importantly stent thrombosis and repeat revascularizations, compared with angiography alone guided PCI.

Clinical Outcomes of Deferred Lesions by IVUS Versus FFR-Guided Treatment Decision

BACKGROUND

There are limited data regarding the safety of deferral of percutaneous coronary intervention based on intravascular ultrasound (IVUS) findings. The current study sought to compare the prognosis between deferred lesions based on IVUS and fractional flow reserve (FFR)-guided treatment decision.

METHODS

This study is a post hoc analysis of the FLAVOUR randomized trial (Fractional Flow Reserve and Intravascular Ultrasound for Clinical Outcomes in Patients With Intermediate Stenosis) that compared 2-year clinical outcomes between IVUS- and FFR-guided treatment decision on intermediate coronary artery lesions using predefined criteria. In both IVUS and FFR groups, vessels were classified into deferred or revascularized vessels, and patients were classified as those with or without deferred lesions. Vessel-oriented composite outcomes (cardiac death, target vessel myocardial infarction, or target vessel revascularization) in deferred vessels and patient-oriented composite outcomes (death, myocardial infarction, or any revascularization) in patients with deferred lesions were compared between the IVUS and FFR groups.

RESULTS

A total of 1682 patients and 1820 vessels were analyzed, of which 922 patients and 989 vessels were deferred. At 2 years, there was no difference in the cumulative incidence of vessel-oriented composite outcomes in deferred vessels between IVUS (n=375) and FFR (n=614) groups (3.8% versus 4.1%; hazard ratio, 0.91 [95% CI, 0.47-1.75]; P=0.77). The risk of vessel-oriented composite outcomes was comparable between deferred and revascularized vessels following treatment decision by IVUS (3.8% versus 3.5%; hazard ratio, 1.09 [95% CI, 0.54-2.19]; P=0.81) and FFR (4.1% versus 3.6%; hazard ratio, 1.14 [95% CI, 0.56-2.32]; P=0.72). In comparison of patient-oriented composite outcomes in patients with deferred lesions, there was no significant difference between the IVUS (n=357) and FFR (n=565) groups (6.2% versus 5.9%; hazard ratio, 1.05 [95% CI, 0.61-1.80]; P=0.86).

CONCLUSIONS

In patients with intermediate coronary artery stenosis, deferral of percutaneous coronary intervention based on IVUS-guided treatment decision showed comparable risk of clinical events with FFR-guided treatment decision.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02673424.

Clinical Benefit of Intravascular Imaging Compared With Conventional Angiography in Left Main Coronary Artery Intervention

BACKGROUND

The RENOVATE-COMPLEX-PCI (Randomized Controlled Trial of Intravascular Imaging Guidance Versus Angiography-Guidance on Clinical Outcomes After Complex Percutaneous Coronary Intervention) demonstrated that intravascular imaging-guided percutaneous coronary intervention (PCI) improved clinical outcome compared with angiography-guided PCI for patients with complex coronary artery lesions. This study aims to assess whether the prognostic benefit of intravascular imaging-guided procedural optimization persists in patients undergoing PCI for left main coronary artery disease.

METHODS

Of 1639 patients enrolled in the RENOVATE-COMPLEX-PCI, 192 patients with left main coronary artery disease were selected for the current prespecified substudy. Selected patients were randomly assigned to either the intravascular imaging-guided PCI group (n=138) or the angiography-guided PCI group (n=54). The primary end point was target vessel failure defined as a composite of cardiac death, target vessel-related myocardial infarction, or clinically driven target vessel revascularization.

RESULTS

At a median follow-up of 2.1 years (interquartile range 1.1 to 3.0 years), intravascular imaging-guided PCI was associated with lower incidence of primary end point compared with angiography-guided PCI (6.8% versus 25.1%; hazard ratio, 0.31 [95% CI, 0.13-0.76]; P=0.010). This significant reduction in primary end point was mainly driven by a lower risk of cardiac death or spontaneous target vessel-related myocardial infarction (1.6% versus 12.7%; hazard ratio, 0.16 [95% CI, 0.03-0.82]; P=0.028). Intravascular imaging-guided PCI was independently associated with a lower risk of primary end point, even after adjusting for various clinical factors (hazard ratio, 0.29 [95% CI, 0.12-0.72]; P=0.007).

CONCLUSIONS

Intravascular imaging-guided PCI showed clinical benefit over angiography-guided PCI for left main coronary artery disease in reducing the risk of cardiac death, target vessel-related myocardial infarction, or target vessel revascularization.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03381872.

Intravascular imaging guided versus coronary angiography guided percutaneous coronary intervention: systematic review and meta-analysis

OBJECTIVE

To assess the absolute treatment effects of intravascular imaging guided versus angiography guided percutaneous coronary intervention in patients with coronary artery disease, considering their baseline risk.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed/Medline, Embase, and Cochrane Library databases up to 31 August 2023.

STUDY SELECTION

Randomized controlled trials comparing intravascular imaging (intravascular ultrasonography or optical coherence tomography) guided versus coronary angiography guided percutaneous coronary intervention in adults with coronary artery disease.

MAIN OUTCOME MEASURES

Random effect meta-analysis and GRADE (grading of recommendations, assessment, development, and evaluation) were used to assess certainty of evidence. Data included rate ratios and absolute risks per 1000 people for cardiac death, myocardial infarction, stent thrombosis, target vessel revascularization, and target lesion revascularization. Absolute risk differences were estimated using SYNTAX risk categories for baseline risks at five years, assuming constant rate ratios across different cardiovascular risk thresholds.

RESULTS

In 20 randomized controlled trials (n=11 698), intravascular imaging guided percutaneous coronary intervention was associated with a reduced risk of cardiac death (rate ratio 0.53, 95% confidence interval 0.39 to 0.72), myocardial infarction (0.81, 0.68 to 0.97), stent thrombosis (0.44, 0.27 to 0.72), target vessel revascularization (0.74, 0.61 to 0.89), and target lesion revascularization (0.71, 0.59 to 0.86) but not all cause death (0.81, 0.64 to 1.02). Using SYNTAX risk categories, high certainty evidence showed that from low risk to high risk, intravascular imaging was likely associated with 23 to 64 fewer cardiac deaths, 15 to 19 fewer myocardial infarctions, 9 to 13 fewer stent thrombosis events, 28 to 38 fewer target vessel revascularization events, and 35 to 48 fewer target lesion revascularization events per 1000 people.

CONCLUSIONS

Compared with coronary angiography guided percutaneous coronary intervention, intravascular imaging guided percutaneous coronary intervention was associated with significantly reduced cardiac death and cardiovascular outcomes in patients with coronary artery disease. The estimated absolute effects of intravascular imaging guided percutaneous coronary intervention showed a proportional relation with baseline risk, driven by the severity and complexity of coronary artery disease.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42023433568.

Long-Term Evaluation of Revascularization Strategies for Medina 0.1.0 Left Main Bifurcation Lesions: The LM-CROSSOVER Registry

The present study aimed to compare long-term outcomes of patients with Medina 0.1.0 left main (LM) bifurcation lesions treated by crossover stenting (COS) versus accurate ostial stenting (AOS). A total of 229 consecutive eligible patients with Medina 0.1.0 LM bifurcation lesions were enrolled and were stratified according to the stenting techniques. The primary end-point was major cardiovascular and cerebral events (MACCE), defined as the combination of all-cause death, target vessel related-myocardial infarction (MI), clinically driven target lesion revascularization (TLR), stroke, or stent thrombosis. COS and AOS were applied to 78 (34%) and 151 (66%) patients, respectively. During a mean of 40.6 ± 21.1 months of follow-up, the rate of MACCE (27.8 vs 12.8%; P=.007) was higher in patients treated with AOS than those treated with the COS technique, mainly driven by more frequent all-cause death (13.9 vs 3.8%, P = .013) and TLR (6.4 vs 15.9%; P = .029). In multivariable Cox regression analysis, AOS strategy was one of the independent predictors of MACCE (odds ratio: 2.166; 95% confidence interval, 1.080-4.340; P = .029). The current study suggests that COS was associated with a better long-term MACCE rate and lower all-cause mortality rate than AOS in patients with Medina 0.1.0 LM bifurcation disease.

Intravascular Imaging in Patients With Complex Coronary Lesions and Chronic Kidney Disease

Importance

As patients with chronic kidney disease (CKD) are more likely to have complex coronary lesions, intravascular imaging guidance in percutaneous coronary intervention (PCI) for this population could be potentially beneficial.

Objectives

To investigate whether the outcomes of intravascular imaging-guided procedural optimization would be different according to the presence of CKD.

Design, Setting, and Participants

This was a prespecified substudy of RENOVATE-COMPLEX-PCI, a recently published multicenter randomized clinical trial in Korea studying the benefits of intravascular imaging for complex coronary lesions. Patients with complex coronary lesions, with or without CKD, were enrolled between May 2018 and May 2021. Data were analyzed from January to June 2023.

Interventions

PCI in each group was done either under the guidance of intravascular imaging or angiography alone.

Main Outcomes and Measures

The primary end point was target vessel failure (TVF) at the 3-year point, defined as a composite of cardiac death, target vessel-related myocardial infarction, or clinically driven target vessel revascularization.

Results

A total of 1639 patients (1300 male [79.3%]) treated with PCI for complex coronary lesions were stratified into CKD (296 participants) and non-CKD (1343 participants) groups. The mean (SD) age of each group was 70.3 (9.4) and 64.5 (10.1) years, and mean (SD) estimated serum creatinine was 2.9 (5.3) and 0.8 (0.2) mg/dL for CKD and non-CKD groups, respectively. Intravascular imaging-guided revascularization was associated with significantly lower incidence of the primary end point compared with angiography-guided revascularization in both CKD (13.3% vs 23.3%; hazard ratio [HR], 0.51; 95% CI, 0.27-0.93; P = .03) and non-CKD (6.4% vs 9.9%; HR, 0.66; 95% CI, 0.44-0.99; P = .05) groups. The significantly lower incidence of the primary end point was mainly associated with the lower risk of cardiac death or target vessel-related myocardial infarction (9.4% vs 22.2%; HR, 0.39; 95% CI, 0.20-0.76; P = .006) in the CKD group and by target vessel revascularization (3.0% vs 5.5%; HR, 0.55; 95% CI, 0.30-0.99; P = .05) in the non-CKD group. Those with a glomerular filtration rate of at least 30 mL/min/1.73m2 and less than 60 ml/kg/1.73m2 showed the greatest benefit from imaging-guided complex PCI (8.8% vs 21.2%; HR, 0.28; 95% CI, 0.11-0.68; P = .02).

Conclusions and Relevance

In this prespecified cohort substudy of the Randomized Controlled Trial of Intravascular Imaging Guidance versus Angiography-Guidance on Clinical Outcomes After Complex Percutaneous Coronary Intervention trial, intravascular imaging guidance showed clinical benefit over angiography guidance in reducing the risk of TVF, regardless of the presence of CKD. The greatest benefits of imaging-guided complex PCI were observed in stage 3 CKD.

Trial Registration

ClinicalTrials.gov Identifier: NCT03381872.

Acute Coronary Syndrome with Non-Obstructive Plaque on Angiography and Features of Vulnerable Plaque on Intracoronary Optical Coherence Tomography

Optical coherence tomography (OCT) has a high spatial resolution and is useful in identifying coronary lesions with high-risk features (vulnerable plaques). These plaques are strongly associated with acute coronary syndrome (ACS). In this report, we present the case of a 43-year-old male patient presenting with typical chest pain that began three hours prior to admission. The patient exhibited an elevation of the ST segments of the anterior and lateral walls. Invasive stratification revealed a 40% lesion in the middle segment of the left anterior descending (LAD) artery. The patient was given optimized clinical treatment as he had a nonobstructive lesion in the LAD at the time of angiography. During the treatment, the patient continued to complain of angina on exertion. A follow-up coronary angiography, along with OCT analysis of the middle-to-moderate lesion in the LAD, revealed a plaque predominantly rich in lipids with signs of vulnerability. A percutaneous coronary intervention was performed. The patient's recovery was uneventful, and he was discharged the day after the procedure. This case illustrates the evolution of intravascular imaging, particularly OCT, in the detection of vulnerable plaques.

State-of-art review: intravascular imaging in percutaneous coronary interventions

The history of intravascular ultrasound (IVUS) and optical coherence tomography (OCT) reflects the relentless pursuit of innovation in interventional cardiology. These intravascular imaging technologies have played a pivotal role in our understanding of coronary atherosclerosis, vascular pathology, and the interaction of coronary stents with the vessel wall. Two decades of clinical investigations demonstrating the clinical efficacy and safety of intravascular imaging modalities have established these technologies as staples in the contemporary cardiac catheterization lab's toolbox and earning their place in revascularization clinical practice guidelines. In this comprehensive review, we will delve into the historical evolution, mechanisms, and technical aspects of IVUS and OCT. We will discuss the expanding evidence supporting their use in complex percutaneous coronary interventions, emphasizing their crucial roles in optimizing patient outcomes and ensuring procedural success. Furthermore, we will explore the substantial advances that have propelled these imaging modalities to the forefront of contemporary interventional cardiology. Finally, we will survey the latest developments in the field and explore the promising future directions that have the potential to further revolutionize coronary interventions.

The Racial Differences in the Clinical Outcomes of Intravascular Ultrasound-Guided Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis

Intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) has been reported to significantly reduce major adverse cardiac events (MACEs) compared with angiography-guided PCI. We aimed to explore whether there were racial differences regarding the beneficial effects of IVUS-guided PCI. Randomized controlled trials for comparison of clinical outcomes between IVUS-guided and angiography-guided PCI were retrieved from PubMed, Web of Science, Embase, and the Cochrane Library from inception to March 15, 2023. The clinical outcomes included MACE, all-cause mortality, myocardial infarction (MI), target vessel revascularization (TVR), target lesion revascularization (TLR), and stent thrombosis (ST). Finally, 18 randomized controlled trials were included in this study (8 in East Asian patients and 10 in Western patients). Results showed that IVUS-guided PCI was associated with a significant reduction of MACE, TVR, TLR, and ST, but not all-cause mortality and MI in both East Asian and Western patients. The reduction of MACE was more significant in East Asian patients (odds ratio [OR] 0.57, 95% confidence interval [CI] 0.46 to 0.70) than that in Western patients (OR 0.83, 95% CI 0.67 to 1.02). Meta-regression analysis revealed that the country the study was performed in (East Asian vs Western countries) was associated with significant heterogeneity between groups, suggesting that racial differences existed (p = 0.033). In conclusion, IVUS-guided PCI was associated with a lower risk of MACE, TLR, TVR, and ST, but not all-cause mortality and MI in both East Asians and Westerners. East Asians benefited more than Westerners upon using IVUS-guided PCI in reducing MACE, suggesting that racial differences do exist between different imaging methods. Larger-sample studies are warranted for further clarification of our findings.

Management of Residual Risk in Chronic Coronary Syndromes. Clinical Pathways for a Quality-Based Secondary Prevention

Chronic coronary syndrome (CCS), which encompasses a broad spectrum of clinical presentations of coronary artery disease (CAD), is the leading cause of morbidity and mortality worldwide. Recent guidelines for the management of CCS emphasize the dynamic nature of the CAD process, replacing the term "stable" with "chronic", as this disease is never truly "stable". Despite significant advances in the treatment of CAD, patients with CCS remain at an elevated risk of major cardiovascular events (MACE) due to the so-called residual cardiovascular risk. Several pathogenetic pathways (thrombotic, inflammatory, metabolic, and procedural) may distinctly contribute to the residual risk in individual patients and represent a potential target for newer preventive treatments. Identifying the level and type of residual cardiovascular risk is essential for selecting the most appropriate diagnostic tests and follow-up procedures. In addition, new management strategies and healthcare models could further support available treatments and lead to important prognostic benefits. This review aims to provide an overview of the diagnostic and therapeutic challenges in the management of patients with CCS and to promote more effective multidisciplinary care.

Comparison of intravascular ultrasound, optical coherence tomography, and conventional angiography-guided percutaneous coronary interventions: A systematic review, network meta-analysis, and meta-regression

BACKGROUND

Intracoronary imaging modalities, including intravascular ultrasound (IVUS) and optical coherence tomography (OCT), provide valuable supplemental data unavailable on coronary angiography (CA) and have shown to improve clinical outcomes. We sought to compare the clinical efficacy of IVUS, OCT, and conventional CA-guided percutaneous coronary interventions (PCI).

METHODS

Frequentist and Bayesian network meta-analyses of randomized clinical trials were performed to compare clinical outcomes of PCI performed with IVUS, OCT, or CA alone.

RESULTS

A total of 28 trials comprising 12,895 patients were included. IVUS when compared with CA alone was associated with a significantly reduced risk of major adverse cardiovascular events (MACE) (risk ratio: [RR] 0.74, 95% confidence interval: [CI] 0.63-0.88), cardiac death (RR: 0.64, 95% CI: 0.43-0.94), target lesion revascularization (RR: 0.68, 95% CI: 0.57-0.80), and target vessel revascularization (RR: 0.64, 95% CI: 0.50-0.81). No differences in comparative clinical efficacy were found between IVUS and OCT. Rank probability analysis bestowed the highest probability to IVUS in ranking as the best imaging modality for all studied outcomes except for all-cause mortality.

CONCLUSION

Compared with CA, the use of IVUS in PCI guidance provides significant benefit in reducing MACE, cardiac death, and revascularization. OCT had similar outcomes to IVUS, but more dedicated studies are needed to confirm the superiority of OCT over CA.

Comparison of definitions of coronary artery reference sizes and effects on stent selection and evaluation of stent expansion

Accurate determination of coronary reference size is essential for optimal stent selection and evaluation of stent expansion during percutaneous coronary intervention (PCI). Several approaches for reference size estimation have been published with no universal agreement. The aim of this study was to investigate if potential differences in coronary reference size estimation lead to differences in stent and balloon selection and in detection of stent under expansion. Definitions for coronary reference size estimation, stent size selection, and stent expansion were identified in 17 randomized controlled trials. The identified methods were applied in a population of 32 clinical cases. Reference size estimates ranged up to 1.35mm, and indicated nominal stent size ranged up to 1.0 mm in the same case depending on method. Mean relative stent expansion ranged from 54±12% to mean 100±29% depending on the applied reference method. Choice of method for reference size estimation using intravascular imaging may influence stent selection and greatly affects evaluation of post-PCI stent expansion.

Accuracy of IVUS-Based Machine Learning Segmentation Assessment of Coronary Artery Dimensions and Balloon Sizing

Background

Accurate intravascular ultrasound (IVUS) measurements are important in IVUS-guided percutaneous coronary intervention optimization by choosing the appropriate device size and confirming stent expansion.

Objectives

The purpose of this study was to assess the accuracy of machine learning (ML) automatic segmentation of coronary artery vessel and lumen dimensions and balloon sizing.

Methods

Using expert analysis as the gold standard, ML segmentation of 60 MHz IVUS images was developed using 8,076 IVUS cross-sectional images from 234 patients, which were randomly split into training (83%) and validation (17%) data sets. The performance of ML segmentation was then evaluated using an independent test data set (437 images from 92 patients). The endpoints were the agreement rate between ML vs experts' measurements for appropriate balloon size selection, and lumen and acute stent areas. Appropriate balloon size was determined by rounding down from the mean vessel diameter or rounding up from the mean lumen diameter to the next balloon size. The difference of lumen area ≥0.5 mm2 was considered as clinically significant.

Results

ML model segmentation correlated well with experts' segmentation for training data set with a correlation coefficient of 0.992 and 0.993 for lumen and vessel areas, respectively. The agreement rate in lumen and acute stent areas was 85.5% and 97.0%, respectively. The agreement rate for appropriate balloon size selection was 70.6% by vessel diameter only and 92.4% by adding lumen diameter.

Conclusions

ML model IVUS segmentation measurements were well-correlated with those of experts and selected an appropriate balloon size in more than 90% of images.

Utilization of intravascular imaging in elective non chronic total occlusion percutaneous intervention and chronic total occlusion percutaneous intervention: Trends in utilization and impact on in-hospital mortality

OBJECTIVES

The objectives of this retrospective study include outcomes associated with and without intravascular imaging in cases of elective single vessel (SV) CTO PCI and in non-CTO PCI.

METHOD

We explored the NIS database from October 1, 2015 to December 31, 2018 to identify 317,090 adult admissions with elective SV PCI. Admissions with STEMI and NSTEMI were excluded to identify elective cases only. Using the ICD 10 diagnosis code for CTO, we identified 33,345 admissions that underwent SV CTO PCI. We classified the remaining cases as SV non-CTO PCI.

RESULTS

Intravascular imaging was utilized in 2930 (8.8%) cases in CTO PCI group and 23,710 (8.3%) cases in non-CTO PCI groups. The utilization of intravascular imaging (IVUS/OCT) significantly increased in elective SV CTO PCI, 6.4%-11.2%, p-trend<0.001 and non-CTO PCI group, 7.3%-9.0%, p-trend<0.001. There was no significance difference in mortality with and without intravascular imaging (combined IVUS/OCT vs no IVUS/OCT: 1.5% vs 1.3%, p = 0.195) in the CTO PCI group. But, in non-CTO PCI admissions, there was a significantly lower in-hospital mortality when intravascular imaging was used (0.7% vs 0.8%, p = 0.003). The cost of hospitalization was significantly higher when intravascular imaging was used in elective single vessel CTO PCI admissions, combined IVUS/OCT vs no IVUS/OCT: $27,427 vs $21,452, p < 0.001 and non-CTO PCI admissions, combined IVUS/OCT vs no IVUS/OCT: $23,620 vs $20,272, p < 0.001.

CONCLUSIONS

In conclusion, despite the cost, intravascular imaging use decrease mortality in non-CTO PCI groups but there is no difference in mortality in CTO PCI groups.

Comparison of Long-Term Outcomes Between Intravascular Ultrasound-, Optical Coherence Tomography- and Angiography-Guided Stent Implantation: A Meta-Analysis

Intravascular ultrasonography (IVUS) and optical coherence tomography (OCT) guided percutaneous coronary interventions (PCI) are alternative techniques to angiography-guided (ANG-g) PCI in patients with coronary artery disease (CAD), especially for optimal stent deployment in coronary arteries. We conducted a network meta-analysis including studies comparing those three techniques. We searched databases for studies that compared IVUS, OCT, and ANG-g PCI in patients with CAD. Overall, 52 studies with 231,137 patients were included in this meta-analysis. ANG-g PCI had higher major adverse cardiovascular events (MACEs), all-cause death, cardiac death, myocardial infarction (MI), target lesion revascularization (TLR), and stent thrombosis (ST) than IVUS-guided PCI. Of note, both OCT-guided and IVUS-guided PCI had similar outcomes. The frequency of MACEs, cardiac death, and MI were higher in ANG-g PCI than in OCT-guided PCI. The highest benefit was established with OCT for MACEs (P-score=.973), MI (P-score=.823), and cardiac death (P-score=.921) and with IVUS for all-cause death (P-score=.792), TLR (P -score=.865), and ST (P-score=.930). This network meta-analysis indicated that using OCT or IVUS for optimal stent implantation provides better outcomes in comparison with ANG-g in patients with CAD undergoing PCI.

Outcomes of Intravascular Ultrasound-Guided Percutaneous Coronary Intervention in Non-ST-Elevation Myocardial Infarction-Propensity Matched Regression Analysis

Intravascular ultrasound (IVUS) guided percutaneous coronary intervention (PCI) is indicated in complex interventions. There is a paucity of evidence for outcomes with large studies on using IVUS during PCI in non-ST-elevation myocardial infarction (NSTEMI). Our objective was to compare the in-hospital outcome of IVUS-guided with that of nonguided PCI among NSTEMI hospitalizations. The National Inpatient Sample (2016 to 2019) was queried to identify all hospitalizations with a principal diagnosis of NSTEMI. In our study, we compared outcomes of PCI with and without IVUS guidance using a multivariate logistic regression model after propensity score matching, with the primary outcome being in-hospital mortality. A total of 671,280 NSTEMI-related hospitalizations were identified, of whom 48,285 (7.2%) underwent IVUS-guided PCI compared with 622,995 (92.8%) who underwent non-IVUS PCI. After adjusted analysis on matched pairs, we found that IVUS-guided PCI had a lower risk of in-hospital mortality than that of non-IVUS PCI (adjusted odds ratio [aOR] 0.736, confidence interval (CI) 0.578 to 0.937, p = 0.013). However, there was a higher use of mechanical circulatory support in the IVUS-guided PCI (aOR 2.138, CI 1.84 to 2.47, p <0.001) than in non-IVUS PCI. The odds of cardiogenic shock (aOR 1.11, CI 0.93 to 1.32, p = 0.233) and procedural complications (aOR 0.794, CI 0.549 to 1.14, p = 0.22) were similar between the cohorts. Hence, we conclude that patients with NSTEMIs who underwent IVUS-guided PCI had less risk of in-hospital mortality and a greater requirement of mechanical circulatory support than did those who underwent non-IVUS PCI, with no difference in procedural complications. Large prospective trials are essential to validate these findings.

Prognostic Impact of Operator Experience and IVUS Guidance on Long-Term Clinical Outcomes After Complex PCI

BACKGROUND

Although consistent clinical data support intravascular ultrasound (IVUS) use during complex percutaneous coronary intervention (PCI), long-term follow-up outcomes on differential effects of IVUS according to operator experience are scarce.

OBJECTIVES

The current study aimed to evaluate the influence of operator experience on lesion complexity, long-term clinical outcomes, and the interactions of IVUS guidance in patients undergoing complex PCI.

METHODS

A total of 6,005 patients who underwent PCI with drug-eluting stents for complex lesions were recruited from the institutional registry of Samsung Medical Center. The study population was stratified by the use of IVUS and operator experience (less experienced operator [lifetime independent experience with PCI ≤5 years] vs experienced operator). The primary endpoint was a composite of cardiac death or target vessel myocardial infarction (TVMI) up to 10 years.

RESULTS

Compared with less experienced operators, experienced operators used IVUS more frequently (29.6% [1,128/3,805] vs 24.8% [546/2,200]; P < 0.001) and achieved a lower risk of cardiac death or TVMI (experienced vs less experienced, adjusted HR: 0.779; 95% CI: 0.663-0.915; P = 0.002). IVUS use was associated with a significantly lower risk of cardiac death or TVMI than angiography alone for less experienced operators (23.5% vs 11.4%; adjusted HR: 0.477; 95% CI: 0.337-0.673; P < 0.001) as well as experienced operators (18.0% vs 13.5%; adjusted HR: 0.747; 95% CI: 0.559-0.998; P = 0.048). There were significant interactions for the risk of cardiac death or TVMI between IVUS use and operator experience (P = 0.037).

CONCLUSIONS

PCI by experienced operators and the use of IVUS during complex PCI were independently associated with lower long-term risks of cardiac death or TVMI. The beneficial effects of IVUS were more prominent for less experienced operators. (Prospective Percutaneous Coronary Intervention Registry [SMC-PCI]; NCT05624905).

Intravascular Ultrasound and Optical Coherent Tomography Combined Catheter

Intravascular ultrasound (IVUS) and optical coherence tomography (OCT) are established intravascular imaging tools for evaluating plaque characteristics and volume, together with guiding percutaneous coronary interventions. The high tissue penetration of IVUS facilitates assessment of the entire vessel wall, whereas the higher resolution of OCT allows detailed assessment of endoluminal structures. A combined IVUS-OCT probe works synergistically, facilitating a greater understanding of de novo coronary artery disease and a better correlation with pathological specimens. In this review, we discuss the rationale and potential roles of the combined IVUS-OCT catheter system.

Intravascular Ultrasound-Guided Percutaneous Coronary Intervention: Evidence and Clinical Trials

The intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) that was associated with improved post-procedural outcomes and long-term clinical outcomes has shown benefits not only in patients with complex lesions but also with simplex lesions. However, the use of IVUS during PCI remains low; therefore, further prospective, randomized, controlled trials are required to strengthen the recommendations and consequently expand its usage. The aim of this review is to discuss the previous evidences and clinical trials regarding IVUS-guided PCI and to discover the necessity for future studies to broaden its use in the real-world clinical practice.

Intravascular Ultrasound-Guided Percutaneous Coronary Intervention: Practical Application

Why is intravascular ultrasounography (IVUS) highly encouraged for the practical guidance of percutaneous coronary intervention (PCI)? First reason is to understand the mechanism of revascularization. Even if stenoses look similar in angiography, the pathophysiology could be different in each lesion. Second reason is to anticipate possible complications in advance. With prediction and appropriate preparation, most complications can be avoided or managed calmly when they occur. Third reason is to optimize PCI results with interactive IVUS use during the procedure. All these are essential to maximize the results of revascularization while minimizing acute complications, ultimately leading to improved long-term clinical outcomes.

Intravascular Imaging-Guided or Angiography-Guided Complex PCI

BACKGROUND

Data regarding clinical outcomes after intravascular imaging-guided percutaneous coronary intervention (PCI) for complex coronary-artery lesions, as compared with outcomes after angiography-guided PCI, are limited.

METHODS

In this prospective, multicenter, open-label trial in South Korea, we randomly assigned patients with complex coronary-artery lesions in a 2:1 ratio to undergo either intravascular imaging-guided PCI or angiography-guided PCI. In the intravascular imaging group, the choice between intravascular ultrasonography and optical coherence tomography was at the operators' discretion. The primary end point was a composite of death from cardiac causes, target-vessel-related myocardial infarction, or clinically driven target-vessel revascularization. Safety was also assessed.

RESULTS

A total of 1639 patients underwent randomization, with 1092 assigned to undergo intravascular imaging-guided PCI and 547 assigned to undergo angiography-guided PCI. At a median follow-up of 2.1 years (interquartile range, 1.4 to 3.0), a primary end-point event had occurred in 76 patients (cumulative incidence, 7.7%) in the intravascular imaging group and in 60 patients (cumulative incidence, 12.3%) in the angiography group (hazard ratio, 0.64; 95% confidence interval, 0.45 to 0.89; P = 0.008). Death from cardiac causes occurred in 16 patients (cumulative incidence, 1.7%) in the intravascular imaging group and in 17 patients (cumulative incidence, 3.8%) in the angiography group; target-vessel-related myocardial infarction occurred in 38 (cumulative incidence, 3.7%) and 30 (cumulative incidence, 5.6%), respectively; and clinically driven target-vessel revascularization in 32 (cumulative incidence, 3.4%) and 25 (cumulative incidence, 5.5%), respectively. There were no apparent between-group differences in the incidence of procedure-related safety events.

CONCLUSIONS

Among patients with complex coronary-artery lesions, intravascular imaging-guided PCI led to a lower risk of a composite of death from cardiac causes, target-vessel-related myocardial infarction, or clinically driven target-vessel revascularization than angiography-guided PCI. (Supported by Abbott Vascular and Boston Scientific; RENOVATE-COMPLEX-PCI ClinicalTrials.gov number, NCT03381872).

'Routine intravascular ultrasound evaluation and change in stenting strategy in primary percutaneous intervention (RIST PCI)'

BACKGROUND

Intravascular ultrasound (IVUS) provides better assessment of vessel size, lesion length and plaque characteristics. There is paucity of data regarding the impact of IVUS on stenting pattern during primary percutaneous intervention (PCI) for ST elevation myocardial infarction (STEMI).

METHODS

We included patients with STEMI undergoing IVUS-guided primary PCI. Diagnostic angiograms were analysed by two different operators who were not part of procedure. They were asked to formulate a treatment plan which included choice of stent diameters, length and number of stents based on angiographic assessment alone. The data were then compared with actual metrics derived from IVUS evaluation.

RESULTS

Sixty-two patients were included. Left anterior descending artery was involved in 38/62(61.3%) cases. Mean stent diameters assessed by angiogram were 2.94 ± 0.4 mm and 3.01 ± 0.32 mm by cardiologist 1 and 2, respectively. IVUS-derived mean stent diameter was 3.5 ± 0.65 mm (p < 0.001). Mean stent length was 42.29 ± 19.29 mm by IVUS evaluation; while angiographically assessed values were 33.53 ± 11.53 (cardiologist 1) and 35.24 ± 12.97 mm (cardiologist 2) with a mean difference of 8.76 mm and 7.05 mm respectively (p < 0.001). Mean number of stents by IVUS evaluation was 1.42 ± 0.56, while by angiographic evaluation were 1.11 ± 0.37 and 1.13 ± 0.34 respectively (p < 0.001).

CONCLUSIONS

There was significant difference between IVUS derived and angiographically assessed culprit vessel metrics in patients undergoing primary PCI. Clinical outcomes of this discrepancy need further studies.

Current clinical use of intravascular ultrasound imaging to guide percutaneous coronary interventions (update)

There are 3 main reasons to promote the practical application of IVUS during PCI. First reason is to understand the mechanism of vessel dilatation. Even if angiographic stenoses are similar, their pathophysiologies are different. It is important to understand what can happen by dilating coronary artery with balloon/stent, and to develop a strategy to achieve the maximum effect. Second reason is to anticipate possible complications and to reduce them in advance. In that case, we can deal with it as calmly as possible. Third reason is to validate the PCI performed. This should lead to further improvements of the procedures, which in turn will lead to improved short- and long-term prognosis. Then, high-quality PCI could be possible. This review summarizes the standard usage of IVUS in routine clinical practice and the use of IVUS in specific situations, especially complex lesions.

Efficacy of intravascular imaging-guided drug-eluting stent implantation: a systematic review and meta-analysis of randomized clinical trials

Background

Traditional angiography only displays two-dimensional images of the coronary arteries during stent implantation. However, intravascular imaging can show the structure of the vascular wall, plaque characteristics. This article aims to evaluate the efficacy of intravascular imaging-guided drug-eluting stent (DES) implantation.

Method

We conducted a systematic review and meta-analysis of randomized controlled trials of intravascular imaging-guided, including patients with DES implantation guided by intravascular ultrasound or optical coherence tomography and traditional angiography. The databases of PubMed, EMBASE, web of science, and Cochrane Library were searched. The primary outcome was target lesion revascularization (TLR). The secondary outcomes included the target vessel revascularization (TVR), myocardial infarction (MI), stent thrombosis (ST), cardiac death, all-cause death, and the major adverse cardiac events (MACE) during the 6–24 months follow-up. The fixed-effects model was used to calculate the relative risk (RR) and 95% confidence interval of the outcome event. Meanwhile, the trial sequence analysis was employed to evaluate the results.

Result

This meta-analysis included fourteen randomized controlled trials with 7307 patients. Compared with angiography-guided, intravascular imaging-guided DES implantation can significantly reduce the risk of TLR (RR 0.63, 0.49–0.82, P = 0.0004), TVR (RR 0.66, 0.52–0.85, P = 0.001), cardiac death (RR 0.58; 0.38–0.89; P = 0.01), MACE (RR 0.67, 0.57–0.79; P < 0.00001) and ST (RR 0.43, 0.24–0.78; P = 0.005). While there was no significant difference regarding MI (RR 0.77, 0.57–1.05, P = 0.10) and all-cause death (RR 0.87, 0.58–1.30, P = 0.50).

Conclusions

Compared with angiography, intravascular imaging-guided DES implantation is associated with better clinical outcomes in patients with coronary artery disease, especially complex lesions (Registered by PROSPERO, CRD 42021289205).

Comparison of Six Different Percutaneous Coronary Intervention Guidance Modalities

Background: New randomized trials and modalities in guiding percutaneous coronary intervention (PCI) have become available. Objective: We aimed to compare the clinical outcomes of coronary angiography (CAG), intravascular ultrasound (IVUS), optical coherence tomography (OCT), fractional flow reserve (FFR), instantaneous wave-free ratio (iFR), and optical frequency domain imaging (OFDI)-guided PCI. Methods: A network meta-analysis was performed to compare different PCI guidance modalities. The clinical outcomes included major adverse cardiovascular events (MACE), all-cause death, myocardial infarction (MI), and target vessel/lesion revascularization (TVR/TLR). Odds ratio (OR) and corresponding 95% credible interval (CrI) were calculated. Results: Thirty-six randomized trials, including 19,042 patients, were included. In comparison with CAG, IVUS significantly reduced MACE (OR: 0.71; 95% CrI: 0.57 to 0.86) and TVR/TLR (OR: 0.53; 95% CrI: 0.43 to 0.66). MACE (OR: 1.44; 95% CrI: 1.02 to 2.08) and TVR/TLR (OR: 1.87; 95% CrI: 1.04 to 3.71) were significantly increased in the FFR group, compared with IVUS group. There were no significant differences in MACE or TVR/TLR among the left guidance modality comparisons. Differences in all-cause death or MI were not observed in any comparisons. Conclusions: IVUS could reduce MACE and TVR/TLR, compared with CAG or FFR. Therefore, IVUS may be the optimal modality in guiding PCI.

Definition of Optimal Optical Coherence Tomography-Based Stent Expansion Criteria: In-Stent Minimum Lumen Area Versus Residual Stent Underexpansion

BACKGROUND

The mismatch between in-stent minimum lumen area (sMLA) and reference vessel lumen area, defined as stent underexpansion (SU), could be an important determinant of stent failure. We tested the clinical predictive value of absolute sMLA in comparison to relative SU in the context of the CLI-OPCI (Centro Per La Lotta Contro L'Infarto-Optimisation of Percutaneous Coronary Intervention) project registry.

METHODS

We retrospectively analyzed end procedural optical coherence tomography findings in 1211 patients (1422 lesions) undergoing percutaneous coronary intervention, assessing the prevalence and magnitude of residual SU and exploring correlation with outcome in comparison with sMLA.

RESULTS

In our series, both sMLA and SU were related to vessel size and anatomic lesion complexity. When compared with patients without adverse event at follow-up, those experiencing device-oriented cardiovascular events (composite of cardiac death, target vessel myocardial infarction, target lesion revascularization, and stent thrombosis) showed a lower sMLA (5.6±2.1 versus 6.1±2.1 mm²; P=0.011) but a comparable degree of SU (11.6±14.1% versus 11.2±13.3%; P=0.734). The prespecified cutoff value of sMLA <4.5 mm², documented in 23.8% of cases, was confirmed as independent outcome predictor for device-oriented cardiovascular events (hazard ratio [HR], 2.05 [95% CI, 1.5-2.9]) including target lesion revascularization (HR, 2.43 [95% CI, 1.7-3.5]) and stent thrombosis (HR, 3.23 [95% CI, 1.7-6.3]). A residual SU of 10%, 20%, and 30% was observed in 38.0%, 18.2%, and 7.6% of cases, respectively. No grade of residual SU significantly increased the risk of stent failure, unless if an SU >20% was associated with an sMLA <4.5 mm² (HR, 3.11 [95% CI, 1.7-5.6]). Finally, an association between stent overexpansion (ie, >110%) and device-oriented cardiovascular events was also observed (HR, 1.60 [95% CI, 1.1-2.3]).

CONCLUSIONS

Final absolute sMLA and not relative SU was associated with an increased risk of stent failure. A variable grade of SU was common, but it resulted in being clinically relevant only when associated with an sMLA <4.5 mm².

Intravascular imaging in coronary stent restenosis: Prevention, characterization, and management

Despite the introduction of drug-eluting stents to combat the neointimal hyperplasia that occurred after BMS implantation, in-stent restenosis is still encountered in a significant number of patients, particularly as increasingly complex lesions are tackled by percutaneous coronary intervention. Many biological and mechanical factors interplay to produce restenosis, some of which are avoidable. Intravascular imaging provided unique insights into various forms of stent-related mechanical issues that contribute to this phenomenon. From a practical perspective, intravascular imaging can therefore help to optimize the stenting procedure to avert these issues. Moreover, once the problem of restenosis eventuates, imaging can guide the management by tackling the underlying identified mechanism. Finally, it can be used to evaluate the re-intervention results. Nevertheless, with the emergence of different treatment options, more evidence is needed to define patient/lesion-specific characteristics that may help to tailor treatment selection in a way that improves clinical outcomes.

Clinical Outcomes Following Hemodynamic Parameter or Intravascular Imaging-Guided Percutaneous Coronary Intervention in the Era of Drug-Eluting Stents: An Updated Systematic Review and Bayesian Network Meta-Analysis of 28 Randomized Trials and 11,860 Patients

Background

Coronary angiography (CAG) is the standard imaging modality for guiding percutaneous coronary interventions (PCI). Intracoronary imaging techniques such as intravascular ultrasound (IVUS) and optical coherence tomography (OCT), and hemodynamic parameter like fractional flow reserve (FFR) can overcome some limitations of CAG.

Objective

We sought to explore the clinical outcomes of different PCI guidance modalities in the era of drug-eluting stent (DES).

Methods

A network meta-analysis of 28 randomized trials and 11,860 patients undergoing different modalities-guided PCI in the era of DES was performed. Odds ratio (OR) with 95% credible interval (CrI) were calculated.

Results

In comparison with CAG, IVUS was associated with a significant reduction in major adverse cardiovascular events (MACE, OR: 0.60; 95% CrI: 0.46–0.79), cardiovascular death (OR: 0.46; 95% CrI: 0.20–0.94), target vessel/lesion revascularization (TVR/TLR, OR: 0.55; 95% CrI: 0.41–0.74), and a trend toward decreased risk of stent thrombosis (OR: 0.44; 95% CrI: 0.17 to 1.00). FFR/quantitative flow ratio (QFR) could significantly reduce stroke compared with CAG, IVUS, and OCT/optical frequency domain imaging (OFDI). However, myocardial infarction (MI), all-cause death, stent thrombosis, and any revascularization presented similar risks for different PCI guidance modalities.

Conclusion

In the era of DES, IVUS led to lower risks of MACE than CAG, which was mainly due to lower risks of cardiovascular death and TVR/TLR. A trend toward decreased risk of stent thrombosis was also observed with IVUS. Hemodynamic parameter (FFR/QFR)-guided PCI could significantly reduce the stroke risk compared with CAG, IVUS, and OCT/OFDI.

Systematic Review Registration

[https://www.crd.york.ac.uk/PROSPERO/], identifier [CRD42021291442].

Percutaneous Coronary Intervention With and Without Intravascular Ultrasound for Patients With Complex Lesions: Utilization, Mortality, and Target Vessel Revascularization

BACKGROUND

Intravascular ultrasound (IVUS) has several benefits during percutaneous coronary interventions (PCIs), including more accurate vessel sizing, improved stent expansion, and better strut apposition. Prior clinical trials have demonstrated a reduction in cardiac events when IVUS is used. However, there is limited information about the utilization of IVUS and the outcomes of IVUS-guided versus angiography-guided PCI in patients with complex lesions in a contemporary population-based setting.

METHODS

New York's PCI registry was used to identify 44 305 patients with complex lesions (lesions that complicate stenting or that require multiple stents) undergoing PCI with and without IVUS guidance and discharged between December 1, 2013 and November 30, 2018. Trends and inter-hospital variation in IVUS use were examined. Risk-adjusted mortality and target vessel revascularization were compared.

RESULTS

A total of 6174 (13.9%) PCI patients underwent IVUS-guided PCI. The median follow-up period was 2.5 years. The percent of patients with complex lesions who underwent IVUS-guided PCI rose from 13.4% in 2014 to 16.5% in 2018 (P<0.0001 for trend), with the main increases occurring in the last 2 years of the period. Only 31 of 66 hospitals in the study used IVUS for >5% of their study patients. IVUS-guided PCI patients experienced significantly lower mortality (adjusted hazard ratio=0.89 [0.79-0.98] after adjustment using a Cox proportional hazards model, and HR=0.88 [0.78-0.99] for propensity-matched patients). We also found that IVUS-guided PCI patients had a lower rate of target vessel revascularization (adjusted hazard ratio=0.88 [0.80-0.97]) after adjusting using Cox proportional hazards with competing risk of mortality and after propensity matching (0.88 [0.79-0.99]).

CONCLUSIONS

Utilization of IVUS for complex lesions has increased but contemporary rates remain low, and there are large inter-hospital variations. The use of IVUS for complex lesions was associated with lower risk of medium-term mortality and target vessel revascularization.

The Clinical Effects of Intravascular Ultrasound-Guided Percutaneous Coronary Intervention in Patients with Chronic Total Occlusion: A Meta-Analysis

Background

The clinical effects of intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) in patients with chronic total occlusion (CTO) lesions remain unclear.

Methods

We identified all full-text published studies that compared the effects of IVUS-guided CTO-PCI with angiography-guided CTO-PCI by searching electric databases including PubMed, Embase, Cochrane Library, and ISI Web of Science from the establishment to Nov 2021. There was no language limitation. The endpoints included the incidence of major adverse cardiac events (MACE), cardiac death, all-cause death, myocardial infarction (MI), and target vessel revascularization (TVR).

Results

Five studies involving a total of 2320 patients were included in this meta-analysis. Compared to the angiography-guided group, IVUS-guided PCI showed no significant reduction in the incidence of MACE (I² = 27.4%, P = 0.239; RR 0.929, 95% CI 0.765 to 1.128, P = 0.457), cardiac death (I² = 0.0%, P = 0.459; RR 0.574, 95% CI 0.299 to 1.103, P = 0.096), all-cause death (I² = 0.0%, P = 0.964; RR 0.677, 95% CI 0.395 to 1.163, P = 0.158), MI (I² = 46.7%, P = 0.131; RR0.836, 95% CI 0.508 to 1.377, P = 0.482), and TVR (I² = 21.2%, P = 0.279; RR 0.929, 95% CI 0.679 to 1.272, P = 0.648).

Conclusions

IVUS-guided PCI demonstrated no significant benefit on MACE, cardiac death, all-cause death, MI, and TVR in patients with CTO lesions. However, given the study's limitations, additional high-quality RCTs are needed.

Current and Future Applications of Artificial Intelligence in Coronary Artery Disease

Cardiovascular diseases (CVDs) carry significant morbidity and mortality and are associated with substantial economic burden on healthcare systems around the world. Coronary artery disease, as one disease entity under the CVDs umbrella, had a prevalence of 7.2% among adults in the United States and incurred a financial burden of 360 billion US dollars in the years 2016–2017. The introduction of artificial intelligence (AI) and machine learning over the last two decades has unlocked new dimensions in the field of cardiovascular medicine. From automatic interpretations of heart rhythm disorders via smartwatches, to assisting in complex decision-making, AI has quickly expanded its realms in medicine and has demonstrated itself as a promising tool in helping clinicians guide treatment decisions. Understanding complex genetic interactions and developing clinical risk prediction models, advanced cardiac imaging, and improving mortality outcomes are just a few areas where AI has been applied in the domain of coronary artery disease. Through this review, we sought to summarize the advances in AI relating to coronary artery disease, current limitations, and future perspectives.

Quantitative coronary angiography versus intravascular ultrasound guidance for drug-eluting stent implantation (GUIDE-DES): study protocol for a randomised controlled non-inferiority trial

INTRODUCTION

Angiography remains the gold standard for guiding percutaneous coronary intervention (PCI). However, it is prone to suboptimal stent results due to the visual estimation of coronary measurements. Although the benefit of intravascular ultrasound (IVUS)-guided PCI is becoming increasingly recognised, IVUS is not affordable for many catheterisation laboratories. Thus, a more practical and standardised angiography-based approach is necessary to support stent implantation.

METHODS AND ANALYSIS

The Quantitative Coronary Angiography versus Intravascular Ultrasound Guidance for Drug-Eluting Stent Implantation trial is a randomised, investigator-initiated, multicentre, open-label, non-inferiority trial comparing the quantitative coronary angiography (QCA)-guided PCI strategy with IVUS-guided PCI in all-comer patients with significant coronary artery disease. A novel, standardised, QCA-based PCI protocol for the QCA-guided group will be provided to all participating operators, while the PCI optimisation criteria will be predefined for both strategies. A total of 1528 patients will be randomised to either group at a 1:1 ratio. The primary endpoint is the 12-month cumulative incidence of target-lesion failure defined as a composite of cardiac death, target-vessel myocardial infarction or ischaemia-driven target-lesion revascularisation. Clinical follow-up assessments are scheduled at 1, 6 and 12 months for all patients enrolled in the study.

ETHICS AND DISSEMINATION

Ethics approval for this study was granted by the Institutional Review Board of Asan Medical Center (no. 2017-0060). Informed consent will be obtained from every participant. The study findings will be published in peer-reviewed journal articles and disseminated through public forums and academic conference presentations. Cost-effectiveness and secondary imaging analyses will be shared in secondary papers.

TRIAL REGISTRATION NUMBER

NCT02978456.

Angiographic-only or intravascular ultrasound-guided approach for left-main coronary artery intervention: a systematic review and meta-analysis

INTRODUCTION

The use of intravascular ultrasound (IVUS) in percutaneous revascularization of left-main coronary artery disease (LMCAD) warrants further exploration. We aimed to collate all available data on the merits of IVUS in LMCAD to help decision-making.

METHODS

The MEDLINE, Embase, and Cochrane databases were queried for relevant randomized controlled trials (RCTs) and observational cohort studies (OCS). The data were analyzed using random-effects model to calculate unadjusted odds ratio (OR) between IVUS-guided and angiography-only LMCA revascularization.

RESULTS

A total of 14 studies (2 RCTs and 12 OCS), comprising 18944 patients, were included. The pooled odds of all-cause mortality (OR 0.57, 95%CI 0.46-0.70, p = <0.00001), cardiovascular mortality (OR 0.37, 95%CI 0.26-0.54, p = <0.00001), left-main revascularization (OR 0.63, 95%CI 0.45-0.89, p = 0.009) and myocardial infarction (OR 0.80, 95% CI 0.66-0.97, p = 0.02) were significantly lower with IVUS-guidance. There was no difference observed in the odds of the stent thrombosis (OR 0.57, 95% CI 0.31-1.05, p = 0.07) and stroke (OR 1.7, 95%CI 0.56-5.14, p = 0.35) between the two groups. A subgroup analysis based on the study design and follow-up duration mirrored the pooled estimates.

CONCLUSION

IVUS-guided LMCA intervention is associated with overall improved cardiovascular outcomes than the angiography-only approach. This needs to be tested in a large randomized controlled trial.

Short- and Long-Term Prognosis of Intravascular Ultrasound-Versus Angiography-Guided Percutaneous Coronary Intervention: A Meta-Analysis Involving 24,783 Patients

Background

Intravascular ultrasound (IVUS) guided percutaneous coronary intervention (PCI) has potential benefits. This meta-analysis aimed to explore whether IVUS-guided PCI had better short- and long-term prognoses than angiography-guided PCI.

Methods

We retrieved studies from PubMed, Embase, and Cochrane Library. Clinical trials including retrospective and randomized controlled trials (RCTs) that compared IVUS-guided PCI with angiography-guided PCI were included. The patients were followed up after operation at 30 days, 1 year, 2 years, and 3 years. The clinical outcomes were target lesion revascularization (TLR), target vessel revascularization (TVR), and MACEs, including stent thrombosis (ST), myocardial infarction (MI), cardiac death, and all-cause death. The study population included patients with MI, coronary bifurcation lesions, short or long lesions, and unprotected left main coronary artery stenosis (ULMCA). The quality of retrospective trials was evaluated using the Newcastle-Ottawa Scale, and the quality of randomized controlled trials was evaluated using the Jadad score. A total of 20 clinical trials met the criteria. Three trials were randomized controlled trials, while 17 were retrospective trials.

Results

A total of 24,783 patients were included. In observational trials, the OR of MACEs was 0.49 (95% CI: 0.38-0.62) in 30 days, 0.65 (95% CI: 0.58-0.73) in one year, 0.51 (95% CI: 0.36-0.71) in two years, and 0.45 (95% CI: 0.31-0.65) in three years. In patients with long coronary lesions, the OR of MACEs in 1 year was 0.64 (95% CI: 0.28-1.50). In patients with left main artery disease, the OR of MACEs in 3 years was 0.42 (95% CI: 0.26-0.67). Compared with angiography-guided PCI, IVUS-guided PCI was associated with a lower incidence of MACEs during the same following period.

Conclusion

Compared with angiography-guided PCI, IVUS-guided PCI has better performance in reducing the occurrence of MACEs.

Stent visualization methods to guide percutaneous coronary interventions and assess long-term patency

Evaluation of acute percutaneous coronary intervention (PCI) results and long-term follow-up remains challenging with ongoing stent designs. Several imaging tools have been developed to assess native vessel atherosclerosis and stent expansion, improving overall PCI results and reducing adverse cardiac events. Quantitative coronary analysis has played a crucial role in quantifying the extent of coronary artery disease and stent results. Digital stent enhancement methods have been well validated and improved stent strut visualization. Intravascular imaging remains the gold standard in PCI guidance but adds costs and time to the procedure. With a recent shift towards non-invasive imaging assessment and coronary computed tomography angiography imaging have shown promising results. We hereby review novel stent visualization techniques used to guide PCI and assess stent patency in the modern PCI era.